Facet Informed Consent

KMG Medical Group MO, P.C. Informed Consent for Telehealth Services

Effective: March 28, 2022 Last Updated: September 13, 2022

Informed Consent Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services offered by KMG Medical Group MO, P.C. and its affiliated entities KMG Medical Group TX P.A., KMG Medical Group NJ, P.C., KMG Medical Group KS, P.A., and Michael Karagas, M.D., P.C., (collectively defined as “KMG”), may also include chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) output data from medical devices and sound and video files.

The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

KMG physicians (our “providers”) are an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.

Expected Benefits Improved access to care by enabling you to remain in your home while the KMG provider consults and obtains test results at distant / other sites. More efficient care evaluation and management. Obtaining expertise of a specialist as appropriate.

Possible Risks Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies. In rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor. In very rare events, security protocols could fail, causing a breach of privacy of personal medical information. In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors. If you need to receive follow-up care, assistance in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact KMG at:

Facet (855) 658-8855 help@facetcare.com

River (844) 421-1331 help@riversleep.com

Picnic (205) 875-8432 help@picnicallergy.com

By checking the box associated with "Informed Consent", you acknowledge that you understand and agree with the following:

I hereby consent to receiving KMG’s services via telehealth technologies. I understand that KMG and its providers offer telehealth - based medical services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the KMG provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter. I have been given an opportunity to select a provider from KMG prior to the consult, including a review of the provider’s credentials. I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that KMG will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state. I understand there is a risk of technical failures during the telehealth encounter beyond the control of KMG. I agree to hold harmless KMG for delays in evaluation or for information lost due to such technical failures. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, that I will be directed to dial 9 - 1 - 1 immediately and that the KMG providers are not able to connect me directly to any local emergency services. I understand that alternatives to telehealth consultation, such as in - person services are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the KMG provider (e.g.labs or bloodwork). I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the KMG provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history / examination that are personally sensitive to me; (2) ask non - medical personnel to leave the telehealth examination; and / or (3) terminate the consultation at any time. I understand that I will not be prescribed any narcotics for pain, nor is there any guarantee that I will be given a prescription at all. I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.

Additional State-Specific Consents The following consents apply to users accessing the KMG website for the purposes of participating in a telehealth consultation as required by the states listed below: Alaska: I understand my primary care provider may obtain a copy of my records of my telehealth encounter. (AK Stat. 08.64.364). Arizona: I understand I am entitled to all existing confidentiality protections pursuant to A.R.S.§ 12 - 2292. I also understand all medical reports resulting from the telemedicine consultation are part of my medical record as defined in A.R.S.§ 12 - 2291. I also understand dissemination of any images or information identifiable to me for research or educational purposes shall not occur without my consent, unless authorized by state or federal law. (A.R.S.§ 36 - 3602). Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter. (C.G.S.A.§ 19a - 906). D.C.: I have been informed of alternate forms of communication between me and a physician for urgent matters. (17 DCMR § 4618.10). Kentucky: If I am a Medicaid recipient, I recognize I have the option to refuse the telehealth consultation at any time without affecting the right to future care or treatment and without risking the loss or withdrawal of a Medicaid benefit to which I am entitled. I understand that I have the right to be informed of any party who will be present at the site during the telehealth consult and I have the right to exclude anyone from being present I also understand that I have the right to object to the videotaping of the telehealth consultation. (KY Admin.Regs.Tit. 907, 3: 170). Louisiana: I understand the role of other health care providers that may be present during the consultation other than the KMG provider. (46 La.Admin.Code Pt XLV, § 7511). Maryland: Regarding audiologists, speech language pathologists, and hearing aid dispensers, I recognize the inability to have direct, physical contact with the patient is a primary difference between telehealth and direct in -person service delivery. The knowledge, experiences, and qualifications of the consultant providing data and information to the provider of the telehealth services need not be completely known to and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only. (Code of MD Reg. Nebraska: If I am a Medicaid recipient, I retain the option to refuse the telehealth consultation at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. I shall have access to all medical information resulting from the telehealth consultation as provided by law for access to my medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without my written consent. I understand that I have the right to request an in-person consult immediately after the telehealth consult and I will be informed if such consult is not available. (NE Revised Stat. 71 - 8505; NE Admin.Code Tit. 471, Ch. 1). New Hampshire: I understand that the KMG provider may forward my medical records to my primary care or treating provider. (N.H.Rev.Stat.§ 329: 1 - d). New Jersey: I understand I have the right to request a copy of my medical information and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. (NJ Rev.Stat.§ 45: 1 - 62). Pennsylvania: I understand that I may be asked to confirm my consent to behavioral health or tele - psych services. Rhode Island: If I use e - mail or text - based technology to communicate with my KMG provider, then I understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized.I have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy.I acknowledge that my failure to comply with this agreement may result in the KMG provider terminating the e - mail relationship. (Rhode Island Medical Board Guidelines). South Carolina: I understand my medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C.Code 1976 § 40 - 47 - 37). Tennessee: I understand that I may request an in -person assessment before receiving a telehealth assessment if I am a Medicaid recipient. Texas: I understand that my medical records may be sent to my primary care physician. (V.T.C.A., Occupations Code § 111.005). Vermont: I understand that I have the right to receive a consult with a distant - site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. I understand that receiving tele - dermatology or tele - ophthalmology services via KMG does not preclude me from receiving real - time telemedicine or face - to - face services with the distant provider at a future date. (VT Stat.Ann.§ 9361).

Patient Consent I have read this document carefully, and understand the risks and benefits of the telehealth consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telehealth consultation under the terms described herein. By checking the Box containing "INFORMED CONSENT FOR TELEHEALTH SERVICES" I hereby state that I have read, understood, and agree to the terms of this document.